Provider Demographics
NPI:1073970992
Name:SQUIRE, BLAKE W (DC)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:W
Last Name:SQUIRE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735
Mailing Address - Street 2:
Mailing Address - City:PARRISH
Mailing Address - State:FL
Mailing Address - Zip Code:34219-0735
Mailing Address - Country:US
Mailing Address - Phone:407-369-0394
Mailing Address - Fax:
Practice Address - Street 1:5105 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-8140
Practice Address - Country:US
Practice Address - Phone:727-698-6088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 11779111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor